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Chapter 33 Health Promotion and Care of the Older Adult Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Health Care Delivery The health care delivery system is becoming more complex for several reasons. Scientific advances more often delay life-threatening conditions of the past. Life expectancy has substantially increased. More focus has been placed on ethical and legal issues related to life, disease, research, and dying. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 2 Wellness, Health Promotion and Disease Prevention A strong emergence of the holistic movement is changing the perception of health from the absence of disease to a broader definition of wellness. Wellness is based on a belief that each person has an optimal level of function and that even in chronic illness and dying some level of well-being is attainable. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 3 Healthy People 2020 Keeping healthy, active, and moving will require a high standard of assessment and health promotion. Healthy People 2000 set forth the goals of the U.S. Department of Health and Human Services to prevent health risks, unnecessary disease, disability, and death. These recommendations have been updated in Healthy People 2020. The intent of these goals focuses on improving functional independence and the quality of life. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 4 Myths and Realities The myths and stereotypes of aging and older adults are numerous. Most myths are generalizations that focus on the negative aspects of aging. In many cases, research has proven such myths to be inaccurate. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 5 Myth #1 Older people are either cranky or depressed. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 6 Myth #2 Growing old means getting sick. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 7 Myth #3 Senility is inevitable. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 8 Myth #4 Old people don't have sex. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 9 Myth #5 Seniors are incapable of learning anything new. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 10 Myth #6 Older workers are less productive and can't keep up. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 11 Myth #7 Memory loss is inevitable. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 12 Myths & Realities Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 13 Legislation affecting older adults Social Security Act of 1935 This was the first major legislation that attempted to provide financial security for older adults. Objectives were to preserve the rights and dignity of our nation’s older citizens. National Family Caregiver Support Program Program provides a means of addressing the nation’s growing needs of caregivers. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 14 Psychosocial Care of the Older Adult Loss, Grief, and Depression Significant psychosocial changes experienced by the older adults may include personal, social, and economic losses. There are changes in roles and retirement and the loss of significant others. Physical changes can result in losses of independence and space. Some older adults have successful coping strategies for grief or isolation; for others, the stress and grief lead to either short- or long-term depression. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 15 Grief Stages Dr. Elisabeth Kübler-Ross described five stages of dying. Denial is the first stage. “No, not me” is a common response. Anger is stage two. The person thinks “Why me?” Bargaining is the third stage. The person now says “Yes, me, but . . . ” Depression is the fourth stage. The person thinks “Yes, me” and is very sad. Acceptance is stage five. The person is calm and at peace. Dying persons do not always pass through all five stages. Some move back and forth between stages. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 16 The Aging Body Integumentary System Age-related changes Lack of pigment in hair (graying) Thinning hair and baldness Less collagen and elasticity in the skin, with less fat under the skin (wrinkles) Age spots (lentigo) Thinning of the epidermis and reduced numbers of oil and sweat glands Increased fragility of blood vessels, resulting in ecchymosis Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 17 The Aging Body Integumentary System (continued) Assessment Observe skin for signs of excessive dryness or openings in the skin. Observe hair for excessive loss, dryness, or oiliness. Observe the nails for excessive length, sharp edges, brittleness, increased thickening, and yellowing. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 18 Common Concerns Pruritus (itch) Due to reduced glandular secretions and moisture Pressure ulcers (bed sores) Thin skin and lack of subcutaneous fat predispose the older adults to pressure ulcers when fragile skin is compressed between bony prominences of the body. Shearing forces may produce injury via a shearing strain. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 19 The Aging Body Gastrointestinal System Age-related changes Decreased secretion of saliva and enzymes in the intestinal tract Atrophy and decreased tone of the intestine Decreased peristalsis Changes may be intensified by medications, lack of fluids or dietary roughage, and lack of exercise. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 20 The Aging Body Gastrointestinal System (continued) Assessment Assess oral cavity for lesions, dental caries, loose teeth, and halitosis. Assess ability to chew and swallow. Assess for complaints of intestinal cramping. Assess dietary intake and weight. Assess for signs of abdominal distention. Assess bowel elimination and use of laxatives. Assess individual’s ability to control defecation. Assess bowel elimination routes. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 21 GI – Common Concerns Obesity Less food is consumed than in their earlier, more physically active years. Weight loss Gradual weight loss is normal; rapid weight loss may indicate illness and should be reported. Fluids/dehydration Have fluids available and toilet facilities easily accessible. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 22 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 23 The Aging Body Gastrointestinal System (continued) Common concerns and nursing interventions (continued) Oral hygiene Thorough cleansing of the entire mouth structure should be done with a soft-bristled toothbrush in the morning and at bedtime. Loss of appetite Prepare food using color and garnishes, attractive dishes, and table setting with good lighting and bright colors. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 24 The Aging Body Gastrointestinal System (continued) Common concerns and nursing interventions (continued) Gastric reflux Encourage small meals, no eating before bedtime, and elevation of the head of the bed. Food intolerance Lactose intolerance is common. Replace milk with cheese and yogurt. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 25 Gastrointestinal Common concerns and nursing interventions (continued) Dysphagia Add thickeners to liquids; provide upright positioning, with leaning slightly forward with the chin down; reduce distractions. Swallow Study Constipation Ensure adequate fluid, exercise, and a diet that contains fiber. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 26 Urinary System Urinary System Age-related changes Overall, kidney function and bladder capacity decrease with age. The bladder and sphincters lose elasticity and are less responsive to stimulus to urinate. Men commonly experience enlargement of the prostate. Assessment Assess frequency, amount, odor, and consistency of urine. Assess individual’s ability to control urination. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 27 Urinary System (continued) Common concerns and nursing interventions Nocturia Encourage patient to limit fluids in the evening, to take diuretic medications in the morning, and to minimize the hazards for falls. Incontinence Provide frequent and easy access to a bathroom or a urinal or commode. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 28 Cardiovascular System Age-related changes Changes involve loss of structural elasticity. It takes longer for the heart to contract and the chambers to fill. Heart valves become thicker and more rigid. There is a decrease in pacemaker cells, and the electrical conduction is slowed. Resting heart rate may decrease. Arteriosclerosis develops, which increases blood pressure. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 29 Cardiovascular System Cardiovascular System (continued) Assessment Assess for signs of pallor, rubor, or cyanosis. Assess and compare apical and peripheral pulses. Assess capillary refill time. Assess for presence of vertigo or syncope. Assess blood pressure in lying, sitting, and standing positions. Assess for edema. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 30 Respiratory System Respiratory System Age-related changes Tissues of lungs and bronchi become less elastic and more rigid with age. The chest wall is less able to expand because of changes in the skeletal system. Muscles associated with respiration are weakened, so that lung expansion and vital capacity are decreased. Overall, the older person’s air exchange is reduced, and secretions remain in the lungs. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 31 Respiratory Assessment Assess depth, rhythm, and rate of respiration at rest and with activity. Assess the amount of activity the individual is able to tolerate. Assess for the presence of cough, productive or nonproductive. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 32 COPD Respiratory System (continued) Common concerns and nursing interventions Chronic obstructive pulmonary disease (COPD) Encourage adequate intake of fluids. Avoid smoking and air pollution. Avoid crowds and people with upper respiratory infections. Ensure adult receives annual influenza vaccine. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 33 Pneumonia Respiratory System (continued) Common concerns and nursing interventions (continued) Pneumonia Liquefy secretions through adequate intake of fluids and prescribed medications. Assist with removal of secretions by teaching proper coughing technique to improve airway clearance. Promote turning, coughing, and deep breathing to improve gas exchange. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 34 Musculoskeletal System Musculoskeletal System Age-related changes There is a reduction in the number and size of active muscle fibers with decreased muscle strength. Joints become less elastic and flexible with the loss and calcification of cartilage. Demineralization of bone leads to osteoporosis. Changes in the spine bone structure and compression of intravertebral discs result in postural changes such as kyphosis. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 35 Musculoskeletal Assessment Assess ability to stand, move, and perform ADLs. Assess gait, including balance, posture, base of support, size of steps, and ability to turn. Assess for muscle weakness, paralysis, joint edema, pain, or limitations in joint mobility. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 36 The Aging Body Musculoskeletal System (continued) Common concerns and nursing interventions Arthritis Relief of stress on affected joints through the use of rest and assertive devices such as splints, walkers, adapted utensils, and use of clothes with Velcro fasteners Range-of-motion and other forms of mild exercise Heat and gentle massage Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 37 Prevention Falls Maintain an environment that is free of hazards. Increase lighting for decreased vision. Provide assistive devices such as walkers and canes to aid with balance. Teach to sit on the side of bed when arising and to stand for several minutes before walking. Encourage exercises that increase strength, balance, endurance, and body awareness. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 38 Osteoporosis Musculoskeletal System (continued) Common concerns and nursing interventions (continued) Osteoporosis Prevention begins with children and adolescents Diet high in calcium and vitamin D Regular weight-bearing exercise Hormone replacement therapy Calcium supplements Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 39 Endocrine System Endocrine System Common concerns and nursing interventions Noninsulin-dependent diabetes mellitus Goal is to achieve and maintain a normal metabolic state through diet management, weight control, and exercise. Intake should be balanced with recommended amounts of protein, carbohydrates, fats, vitamins, and minerals; refined sugar is limited; high-fiber diet is encouraged. Monitor glucose levels, good foot care, and safety precautions. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 40 Hypothyroidism Assess for weight gain, dry skin, thinning of hair, cold intolerance, delirium, and depression. The goal for interventions is stabilization of thyroid levels with medication (levothyroxine). Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 41 Sensory Perception Sensory Perception Age-related changes Visual impairment Cataracts, glaucoma, macular degeneration, and diabetic retinopathy Presbyopia, narrowing of the peripheral field of vision, decreased ability to focus on near objects, and decrease in visual acuity Depth perception distorted and vision in dim light difficult Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 42 The Aging Body Sensory Perception (continued) Age-related changes (continued) Hearing impairment Presbycusis: the normal loss of hearing acuity, speech intelligibility, auditory threshold, and pitch associated with aging Touch and position Decreased number of receptor cells in the skin and joints Difficulty sensing temperature and maintaining balance Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 43 Sensory Assessment Sensory Perception (continued) Assessment Assess Assess Assess Assess eyes for dryness, tearing, or signs of irritation. ability to see both close up and at a distance. hearing; note the use of hearing aids. for reported changes in taste or smell. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 44 Sensory Interventions Sensory Perception (continued) Common concerns and nursing interventions Decreased vision Ensure that the patient’s eyeglasses are clean and are available. Increase the amount of light in the environment. Reduce glare by use of shades on windows and lights. Use night lights to avoid abrupt light-to-dark changes. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 45 Decreased Hearing Sensory Perception (continued) Common concerns and nursing interventions (continued) Decreased hearing Hearing aids Face the individual and speak at a normal or slightly slower pace without exaggerating or shouting. Nonverbal communication: gestures, smiles, nodding, and written communication Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 46 Peripheral Neuropathy Sensory Perception (continued) Common concerns and nursing interventions (continued) Peripheral neuropathy Teaching the need for careful daily inspection for blisters, cuts, or infections. Avoid smoking, constricting footwear, and crossing of legs. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 47 Age Related Changes Nervous System Age-related changes There is a decline in the number of peripheral nerve cells and fibers, as well as brain cells. Nerve impulse transmission in the nervous system slows, resulting in slower reaction time. Autonomic nervous system changes include decreased efficiency in maintaining normal body temperature and in the pulse returning to normal after exercise or stress. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 48 Nervous System - Assess Nervous System (continued) Assessment Assess Assess Assess Assess Assess alertness level. appropriateness of behavior and responses. changes in memory. for the presence of pain. sleep patterns. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 49 Cognitive Changes Aging has little influence on cognition. Only some older people experience some cognitive deficits. Research indicates that most older people retain their intelligence and are capable of learning throughout their lives. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 50 Cognitive Changes Changes in the brain and nervous system occur with aging. Certain diseases affect the brain. Changes in the brain can affect cognitive function. Cognitive relates to knowledge. Cognitive function involves: Memory Thinking Reasoning Ability to understand Judgment Behavior Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 51 Confusion Confusion has many causes: Diseases and infections Hearing and vision loss Drug side effects Brain injury Age-related changes resulting in reduced blood supply to the brain Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 52 Delirium Acute confusion (delirium) occurs suddenly. It is usually temporary. Causes include infection, illness, injury, drugs, and surgery. Treatment is aimed at the cause. Confusion caused by physical changes cannot be cured. Some measures help to improve function. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 53 Dementia Dementia is the loss of cognitive function that interferes with routine personal, social, and occupational activities. Dementia is a group of symptoms that may occur with certain diseases or conditions. Dementia is not a normal part of aging. Some early warning signs include: Recent memory loss that affects job skills Problems with common tasks Problems with language; forgetting simple words Getting lost in familiar places Misplacing things and putting things in odd places Personality changes Poor or decreased judgment Loss of interest in life Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 54 Alzheimer’s Permanent dementias result from changes in the brain. They have no cure. Alzheimer’s disease is the most common type of permanent dementia. These functions are affected: Memory Thinking Reasoning Judgment Language Behavior Mood Personality Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 55 Alzheimer’s continued…. These behaviors are common with AD: Wandering Sundowning (signs, symptoms, and behaviors of AD increase during hours of darkness) Hallucinations (seeing, hearing, smelling, or feeling something that is not real) Delusions (false beliefs) Catastrophic reactions (extreme responses) Agitation and restlessness Aggression and combativeness Screaming Abnormal sexual behaviors Repetitive behaviors Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 56 Health Care and the Aging Adult Illness Responses Frequently, older adults respond to illness by developing disorientation or delirium, weakness, immobility, incontinence, or by falling. The development of such changes in behavior should be recognized, documented, and reported; they may indicate treatable infection or illness before the typical signs and symptoms are seen. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 57 Security Concerns for the Older Adult Finances Health care can become a major expense and devastate the older adult’s personal financial security. Many have a fixed income from retirement pensions and only limited savings to pay for the rising costs of housing, food, and health care. Financial problems can arise when people have not planned carefully for retirement; retirement planning should begin early in life for both men and women. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 58 Security Concerns for the Older Adult Housing The majority of older adults prefer to remain independent and have their own, noninstitutionalized housing. Other options for living arrangements might include retirement villages or senior housing apartments or single-family homes. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 59 Health Care and the Aging Adult Medications Minimizing adverse effects and drug interactions can be a delicate balancing act. Age-related changes in body function can contribute to adverse reactions. Metabolism of medications is decreased as a result of decreased blood flow to the liver, fewer functioning liver cells, and a decrease in the liver enzymes. Dosages may need to be reduced to prevent toxicity. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 60 Overview of Health and Wellness in the Aging Adult Elder Abuse and Neglect Violence toward individuals over the age of 65 Classifications of abuse Physical or sexual abuse Psychologic abuse Misuse of assets Medical abuse Neglect Indicators of elder abuse Frequent unexplained crying; unexplained fear of or suspicion of a particular person Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 61 Health Care and the Aging Adult Hospitalization, Surgery, and Rehabilitation Older adults have less reserve to cope physically and emotionally with the effects of hospitalization and surgical interventions. They require longer postoperative recovery and convalescent periods. Minimize the normal effects of immobility: stasis of secretions, orthostatic hypotension, and digestive and perceptual disorders. Encourage to perform self-care activities at older adult’s own level of tolerance and to have rest periods. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 62